Tehran University of Medical Sciences Nursing Practice Today 2383-1154 10 1 2023 01 24 4 6 Zahra Yazdani Department of General, Fatemieh Hospital, Isfahan, Iran Shaghayegh Roofeh Department of Pharmacy, Fatemieh Hospital, Isfahan, Iran 2022 10 09 2022 11 26 Introduction: Medicines are the most widely used interventions in health care and adverse drug reactions alone are responsible for 5-10% of hospitalizations in elderly patients. Carbamazepine is an anticonvulsant drug and skin rash is one of its rare symptoms of it. It requires immediate medical attention and is sometimes life-threatening. Case Report: This case report is about a 72-year-old woman who witnessed the interaction of rivaroxaban and carbamazepine, and the side effects of carbamazepine simultaneously. Conclusion: Patient participation and patient-centered tools are needed to promote patient safety. https://npt.tums.ac.ir/index.php/npt/article/view/2222 https://npt.tums.ac.ir/index.php/npt/article/download/2222/554